Number of Pages: 9

Who is it for?

• New client

What is it for?

• A questionnaire to be filled out by guardian for intake

• Form includes the following sections:

  • Medical and psychological history

  • Educational history 

  • Child's strengths and challenges

  • Child's current level of performance in:

    • Language and communication

    • Social-communication skills

    • Other areas: motor, eating, dressing, grooming, hygiene, writing, reading, math

  • Family Priorities & Preferences

Why should you use it?

• To gather information about the client as part of the intake process

• To gather information about the client's skills and needs

• Highly recommend to use it as part of the Intake Packet 

Disclaimer/Recommendations: 

• While this intake questionnaire has sections where guardian can share with provider the skill level of the client, this questionnaire is not intended to replace any assessments.